Research-based social and emotional
An easy, 10-15 minute face-to-face
“interview” with parents of children between 6
months and 5 years of age
A conversation starting tool that helps staff
learn about a child and his/her parent’s
Available in both English and Spanish
Able to be copied- you don’t have to use an
original questionnaire, but can use a copy
It is NOT something you
send home with the
It is NOT used to
diagnose a child
What about the
§ 1304.20 (b) (1):
(b) Screening for developmental, sensory, and
(1) In collaboration with each child's parent, and
within 45 calendar days of the child's entry into
the program, grantee and delegate agencies
must perform or obtain linguistically and age
appropriate screening procedures to identify
concerns regarding a child's developmental,
sensory (visual and auditory), behavioral, motor,
language, social, cognitive, perceptual, and
emotional skills (see 45 CFR 1308.6(b)(3) for
additional information). To the greatest extent
possible, these screening procedures must be
sensitive to the child's cultural background.
The Head Start child must have a new
questionnaire completed at least once a year
within 45 days of enrollment.
Early Head Start:
The Early Head Start child must have a new
questionnaire completed at least every 6 months
until the age of 3.
The ASQ:SE needs to be completed with EHS
children within 2 weeks of the child reaching the
next age (i.e., within 2 weeks of the child turning
18 months old)
The screening form comes in eight different
ages: 6 months, 12 months, 18 months, 24
months, 30 months, 36 months, 48 months,
and 60 months.
Use the child’s chronological age in months
to determine which form to use. The front
page has the age (in months) at which each
form should be used.
In EHS, we start using the 6 month form at 4
Use BLUE INK to fill out the questionnaire!
Sit face-to-face with the parent or guardian
while you ask the questions. DO NOT JUST
SEND HOME WITH THE PARENT!
◦ If not done face to face, the parent may not
understand all questions and may not answer
◦ Doing the questionnaire with the parent will give
you more insight into how to best work with the
child in the classroom
Fill out all of the blanks on page 2 with the
◦ Write the parent’s name in the “Person filling out
this questionnaire” blank
◦ List your (staff’s) name under “List people assisting
in questionnaire completion”
◦ Write the center name in the blank next to
“Administering program or provider”
Go through all of the questions with the child
and mark the appropriate boxes based on the
parent’s response (“Most of the Time”,
“Sometimes”, or “Rarely or Never”).
Also note any “Concerns” the parent has by
marking the circle in the last column for the
Fill out the short answer questions, starting
on page 6, with the parent’s responses.
Fill out the top portion on page 8 with the
same information entered on the front page.
Go back through the questionnaire and tally
up the points using the following point
◦ Z (for zero) next to the checked box =0
◦ V (for Roman numeral V) next to checked box =5
◦ X (for Roman numeral X) next to checked box =10
◦ Checked Concern =5
**NOTE: The codes Z, V, and X do NOT correspond
with a certain column. X could be the first column
or the third. Pay attention to which letter is next to
the marked box on EACH question!
Total the points on each page (3, 4, 5, and 6)
and copy those totals on the appropriate
blanks on page 8.
Add up all four scores and write the total next
to “Child’s total score”.
Take note of those individual questions that
score 10 or 15 points and any written or
verbal comments the parent shares. Use
these as you make referral considerations.
Transfer the child’s total score to the chart in the
lower-middle of the page.
Compare the child’s score with the cutoff score
If the child’s score falls ABOVE the cutoff score,
complete an ICOPA (Individualized Child
Outcome Plan of Action) with the parent.
On the ICOPA, the parent can choose to either
have the child rescreened in 2 weeks or have an
immediate referral to Mental Health & Disability
If the parent requests a referral, fill out a Referral
Form and submit through inter-office mail to
Mental Health & Disability staff.
Remember to document all screenings and
ICOPAs in Child Plus before filing the forms in
the brown folder.
ALL screenings are confidential and need to
be locked up when they are not being used.
What does ASQ:SE
Head Start children must be
screened using the ASQ:SE within
how many days of enrollment?
TRUE or FALSE:
The ASQ:SE can be sent home
with the parent and returned
to the center the next day.
What writing utensil
should you use when
completing the ASQ:SE
What do you need to do
after completing the ASQ:SE
if the child’s score is above
You have now completed the
training for the Ages and Stages
If you have any questions, please
feel free to contact:
Jennifer Crookham: 891-2156
Blanca Herron: 893-5827
Leigh Wells: 893-3167